Different Methods Deployed to Manage Imaging Utilization in U.S. and Canada
Facilitators of an RSNA 2008 session on controlling imaging utilization in the U.S. and Canada offered differing opinions of the forces at work.
 G. Scott Gazelle, M.D., M.P.H, Ph.D. Harvard Medical School |  Walter Kucharczyk, M.D., F.R.C.P. University of Toronto |
"In Canada, utilization of imaging is being managed largely by limiting capacity and the ability to expand capacity," said G. Scott Gazelle, M.D., M.P.H, Ph.D., a professor of radiology at Harvard Medical School in Boston and director of the Institute for Technology Assessment at Massachusetts General Hospital. "In the U.S., utilization is being managed primarily by limiting either the economic incentives to image or the freedom to order, but not capacity, with the exception of determination of need laws. It's really an interesting contrast."
Dr. Gazelle led the special focus session, "Rationing of Imaging Services: Facing the Inevitable Crisis in Resources—U.S. versus Canadian Perspective," with Walter Kucharczyk, M.D., F.R.C.P., a professor of radiology in the Department of Medical Imaging at the University of Toronto.
The session examined present and potential efforts to control imaging utilization in both the U.S. and Canada, comparing and contrasting the way both nations seek to reduce medical costs by limiting the utilization of imaging exams.
Patients Deem New Technology Worth the Money
Diagnostic imaging is one of the fastest growing medical expenditures in the U.S. According to a June 2008 report from the U.S. Government Accounting Office, Medicare spending for imaging services more than doubled between 2000 and 2006, increasing to about $14 billion. Spending on advanced imaging, such as CT, MR imaging and nuclear medicine, rose substantially faster than imaging services such as ultrasound, X-ray and other standard imaging.
Patients, however, do not report having a problem with the rising costs. A 2005 The Wall Street Journal/Harris Interactive Poll indicated that nearly one-third of adults believe that new technologies such as digital imaging devices and electronic medical records are worth the money because they will improve patient care.
"From my perspective, imaging has developed very rapidly over the past two decades, to the point that it is of central importance to patient management for a whole host of diseases," said Dr. Kucharczyk.
Public versus Private Sector a Key Difference
Canada and the U.S. are a little out of sync in how they have developed systems for utilization management, Dr. Kucharczyk added. "The U.S. has private and public sector medical cost payers, while the Canadian system of care is purely public," he said. "The Canadian system has generally disseminated technology slower. The country overall, at least in the 80s and 90s, didn't invest as much in technology. It was all government paid."
Cost controls for imaging in the U.S. have become of increasing importance in the past five years, said Dr. Gazelle. "The interesting thing we've seen recently is the payers, private and public, have become increasingly concerned with the cost of imaging," he said. "They have implemented a variety of strategies to try to limit imaging utilization. The public payers, Medicare principally, have focused primarily on the cost side; that is, they've tried to put downward pressure on costs, hoping that reduced economic incentives will force centers to image less.
"The private payers have focused on more direct discouragement of utilization, using radiology benefit management firms, preauthorization and pay-for-performance clauses in contracts that actually pay you more or withhold money if you cannot control utilization," Dr. Gazelle continued.
Such measures don't exist in Canada, said Dr. Kucharczyk. "We don't have this intermediary," he said. "No one is ever turned away by their insurer because they don't think the exam is indicated. They get turned away indirectly because they have to wait for the exam."
Radiologist's Role Elevated
Whether the controls are direct or indirect, the session presenters agreed that containing costs is a subject that plays a role in medical decision making. This relatively new pressure for radiologists simply highlights their increasing role as expert consultants on each patient's medical team, said Dr. Kucharczyk. "I'm a neuroradiologist dealing mostly with MR imaging, so we're always trying to juggle schedules to fit people in," he said. "You always leave enough gaps in your schedule to get in a person who presents with a serious need. If you don't have a gap, you bump someone who's not as urgent. Emergency situations here always get handled. It's the elective cases that have to wait longer."
The fact that utilization management efforts are under way in Canada, said Dr. Kucharczyk, means the system is always operating at capacity. "We all grew up with the system," he said. "I'll ask, 'Does a test have to be done today? How urgent is it?' If it's a physician you trust, whose opinion you respect, you'll arrange it. But it is time consuming and can be frustrating."
In the U.S., Dr. Gazelle observed, radiologists don't want to be in a situation of saying "no" to referring physicians. "One of the things we've done here at MGH is develop computerized order entry with embedded decision support that we think provides useful information and some control of imaging utilization, by focusing on limiting ordering choices to those instances where we think it's the most appropriate," he said. "It's always been part of the routine care that there's a dialogue, that radiologists are not just people who interpret exams, that they are colleagues who provide consultation."